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Endoscopic Endonasal Approach for Resection of Cranial Base Chordomas: Outcomes and Learning Curve

Koutourousiou, Maria MD*; Gardner, Paul A. MD*; Tormenti, Matthew J. MD*; Henry, Stephanie L. BSN*; Stefko, Susan T. MD; Kassam, Amin B. MD; Fernandez-Miranda, Juan C. MD*; Snyderman, Carl H. MD, MBA*,§,‖

doi: 10.1227/NEU.0b013e31825ea3e0
Research-Human-Clinical Studies

BACKGROUND: Gross total resection (GTR) of cranial base chordomas represents a surgical challenge because of the location, invasiveness, and tumor extension. In the past decade, the endoscopic endonasal approach (EEA) has been used with notable outcomes.

OBJECTIVE: To present the endoscopic endonasal experience in the treatment of cranial base chordomas at our institution.

METHODS: From April 2003 to March 2011, 60 patients underwent an EEA for primary (n = 35) or previously treated (n = 25) cranial base chordomas. We evaluated the degree of GTR and complications. We studied the factors that influenced outcomes and compared our surgical results in the early and late years of our experience.

RESULTS: The overall rate of GTR of cranial base chordomas was 66.7% (82.9% in primary and 44% in previously treated patients). The most important limitations for GTR were tumor volume greater than 20 cm3 (P = .042), tumor location in the lower clivus with lateral extension (P = .022), and previously treated disease (P = .002). The learning curve had a significant impact on GTR, increasing the success rate to 88.9% (92.6% in primary patients and 63.6% in previously treated patients) during recent years (P < .0001). The most frequent complication was cerebrospinal fluid leak (20%) resulting in meningitis in 3.3%. Carotid injuries occurred in 2 patients without any resulting deficit. Neurological complications included new cranial neuropathies (6.7%) and long tract deficits (1.7%). There was no operative mortality in our series.

CONCLUSION: For the treatment of cranial base chordomas, the EEA is a competitive alternative to transcranial approaches with minimal morbidity and high success rates of GTR when performed by experienced cranial base surgeons.

ABBREVIATIONS: CN, cranial nerve

EEA, endoscopic endonasal approach

GTR, gross total resection

ICA, internal carotid artery

LOS, length of hospital stay

Departments of *Neurological Surgery

Ophthalmology, and

§Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada

Departments of Otolaryngology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Correspondence: Paul A. Gardner, MD, Department of Neurosurgery, UPMC Presbyterian, 200 Lothrop Street, Suite B400, Pittsburgh, PA 15213. E-mail:

Received September 26, 2011

Accepted April 25, 2012

Copyright © by the Congress of Neurological Surgeons